Dr. J. Satish Kumar, MD, Department of Basic & Medical Sciences, AUST General Medicine CVS Name:________________________________________ Infective Endocarditis

Infective Endocarditis-Introduction Infective endocarditis (IE) is a disease that produces vegetations on the endocardium. It is virtually always fatal if untreated. A heart valve is usually involved, but the infection may develop on a septal defect or on the mural endocardium. Two major predisposing causes – susceptible cardiovascular substrate – a source of bacteremia. Infective Endocarditis

Classification Progression: – Acute: days-6 wks, Staphylococcus aureus – Subacute:6wks-1yr, Viridans streptococci Valve: – Native – Native: 75% Viridans streptococci, Enterococci … – Prosthetic – Prosthetic: 50% S. epidermidis & aureus, G-& fungi – Iv drug abusers – Iv drug abusers: 50% S. aureus, streptococci & enterococci, Infective Endocarditis

Pathogenesis of C.F ↓ Infective endocarditis (Infected vegetation) ↓ 1.Constant bacteremia 2.Circulation immune complexes 3.Local tissue destruction 4.Infected emboli Infective Endocarditis

Clinical Manifestations Fever>95% Arthralgias and/or myalgias 25-45% Murmur>85% Splenomegaly25-60% Petechiae20-40% Splinter hemorrhages 10-30% Roth ’ s spots<5% Osler ’ s nodes10-25% Janeway lesions<5% Clubbing 10-20% Clinically apparent emboli 25-45% Neurologic manifestations 20-40% Infective Endocarditis

Osler’s Nodes and Janeway’s Lesions

Janeway lesions They are non-tender, small erythematous or haemorrhagic macular or nodular lesions on the palms or soles only a few millimeters in diameter that are pathognomonic of infective endocarditis.tendererythematous haemorrhagicmacularnodular palmssolespathognomonicinfective endocarditis They are caused by septic emboli which deposit bacteria, forming microabscesses. Janeway lesions are distal, flat, ecchymotic, and painless.ecchymotic Osler's nodes and Janeway lesions are similar, but Osler's nodes present with tenderness. Osler's nodes Infective Endocarditis

Predisposing Factors Aged – Degenerative valvular dz. – Increased exposure to nosocomial bacteremia – Prosthetic valves Gender (M>F) Associated medical conditions : – Long term HD – DM – Poor dental hygiene – HIV – Congenital defects MVP – MR – Thickened leaflets ASD, VSD – Injection-drug use (TV) – Long-term indwelling intravenous catheters – Rheumatic heart dz. (primarily the young in developing countries)

Laboratory Manifestations Anemia70-90% Leukocytosis20-30% Proteinuria50-65% Microscopic hematuria 30-50% ↑serum creatinine10-20% ↑ESR>90% Rheumatoid factor50% Circulating immune complexes65-100% ↓serum complement 5-40% Infective Endocarditis

Diagnosis Criteria The diagnosis of infective endocarditis requires the integration of – Clinical – laboratory – echocardiographic data. Modified Duke criteria -by Li JS et al. Clin Infect Dis 2000 Modified Duke criteria Infective Endocarditis

Cardiac Complications Congestive heart failure – Infection-induced valvular damage – Myocardial infarction: embolism of fragments of vegetations – Aortic-valve infection Erosion of a mycotic aneurysm of the sinus of Valsalva Pericarditis, hemopericardium and tamponade, or fistulas to the right or left ventricle – mitral-valve infection Infective Endocarditis

Other Complications Neurologic: – 65% of embolic events in IE involve CNS & develop neurologic complications – Embolic events ↓rapidly after 2wks effective antibiotic therapy Systemic Emboli and Splenic Abscess Prolonged Fever Infective Endocarditis

Treatments Medical: – Antimicrobial Agents – Anticoagulant Therapy: not recommended Surgical: – Indications: Congestive heart failure is the strongest indication for surgery Special microorganisms: – Pseudomonas aeruginosa, brucella species, Coxiella burnetii, candida species, other fungi, and probably enterococci IE involving a prosthetic valve Infective Endocarditis